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Purpose Cardiopulmonary Exercise Testing (CPET) is the clinical standard to select HF pts for cardiac replacement therapy. INTERMACS profile is used to risk stratify pts who undergo LVAD. We aimed to evaluate the association of CPET performance parameters with INTERMACS profile at implant as well as with clinical outcomes early post LVAD. Methods A retrospective analysis of LVAD pts implanted from 3/10 to 5/19 with CPET data available within 2y of surgery: peak oxygen consumption (pVO2) and minute ventilation − carbon dioxide production relationship (VE/VCO2). The primary endpoints were INTERMACS profile ≤2 at implant and a composite of post LVAD in-hospital mortality, right ventricular failure (RVF) and renal replacement therapy (RRT). Length of stay (LOS) in relation to CPET performance parameters was also evaluated. Receiver Operating Characteristics (ROC) curve assessed the ability of pVO2 and VE/VCO2 to predict the composite endpoint. Results We studied 81 pts, median age 58 [IQR 16.5] y, 86% M, 41% ischemic, 48% HMII, 40% HM3 and 12% on other pumps. Median time from CPET to LVAD implant was 233 [388]d. Median pVO2 was 11.9[IQR 4.4] ml/kg/min and VE/VCO2 38 [IQR 10.3]. 46(56.8%) pts were INTERMACS ≤2 at implant. 6 pts died, 7 had RRT and 23 developed RVF during index admission. PVO2 and VE/VCO2 were not significantly different between INTERMACS ≤2 vs >2 groups (p=0.8 and p=0.15, respectively). ROC curves showed that pVO2 Conclusion In a real-world setting, CPET parameters obtained within 2 y of LVAD do not reliably predict INTERMACS profile at implant. However, pVO2 and VE/VCO2 can be helpful to identify pts at risk for in-hospital mortality, major complications and prolonged LOS post LVAD.

Purpose Socioeconomic deprivation may impede referral for heart transplant (HT) evaluation and impart barriers to listing. The area deprivation index (ADI) incorporates Census-derived measures of neighborhood disadvantage that include education, employment, income, poverty, and housing characteristics. We examined the association of ADI with HT listing among patients evaluated at our institution. Methods All HT evaluations at our institution from 1/1/2017-12/31/19 were reviewed. Patient sex, age, race, ethnicity, BMI, and primary insurance payer were recorded. Block group-level ADI decile (1-10 with 10 being the most disadvantaged) was obtained at each patient's home address. Results Of 330 patients evaluated for HT, 262 were presented at our selection meeting. ADI was obtained for 259 patients and assigned by multiple imputation for three. Among them, 27% were women, 54% white, 22% Black, and 16% Latino. Median age was 59 years (IQR 48-55) and median ADI decile was 4 (2-7). Our institutional neighborhood ADI is 9. In total, 206 (79.5%) candidates were listed for HT. ADI decile did not associate significantly with odds of listing (OR 0.94 [95% CI 0.85-1.04],p=0.21). Compared to those with commercial insurance, patients with Medicare (OR 0.36 [0.16-0.79],p=0.01) and dual coverage (OR 0.17 [0.06-0.44],p Conclusion Among candidates presented for HT evaluation at our center, ADI did not associate with likelihood of listing. Lower listing odds for patients supported with Medicare or dual coverage may reflect longstanding illness. Additional studies will determine associations of ADI and insurance with bridging strategy, waitlist and post-HT outcomes.

Purpose We aimed to examine the effectiveness of serial follow-up phone calls as an intervention after clinic visits to enhance compliance with cancer surveillance among heart transplant (HT) patients. Methods 41 HT cancer-free patients were randomized to intervention (n=21) vs. control (n=20) groups. Time Series Design was used; the intervention group received 4 calls post clinic visits within 31 days at different point intervals between 7-10 days, addressing the patient's specific needs for cancer screening based on immunotherapy and medical issues. The control group received 1 phone call at the end of the study. Chi-Square Statistics was used to compare screening rates between intervention and control groups. Results Mean age was 60.3 years, 78% male, and 24% had prior malignancy. 39% of patients were studied 1-5 years post HT, 20% 5-10 years; 26% 10-14 years; and 15% 15-20 years. Main reasons for non-compliance reported by patients were: “too busy”, “family issues”, and “I forgot”. At the end of the study, 50% of patients were fully compliant with cancer screening recommendations in the intervention group vs. 15% in the control group. This difference was statistically significant: (X2 (1)= 4.062, p= 0.044) (Fig. 1a). Compliance rates after each phone call are shown in Fig. 1b. Conclusion A nurse practitioner-led follow-up phone calls program is a feasible and effective strategy to increase compliance with de novo cancer screening among adult heart transplant recipients. Additional studies are needed to validate the usefulness of this approach in this unique patient population.

Purpose Use of statin therapy in heart transplant (HT) recipients offers the dual benefits of lipid control and as an anti-rejection agent. It is unknown whether PCSK9 inhibitors are safe and effective in transplant recipients and whether there might be similar anti-rejection or anti-inflammatory benefits in this patient population. Methods We identified eight patients in our outpatient HT clinic who were either statin intolerant (defined by myositis or transaminitis) or with refractory hyperlipidemia (defined as LDL > 80 in patients with cardiac allograft vasculopathy [CAV] or LDL > 120 in patients without prior CAV). Baseline demographics including lipid parameters and presence or absence of CAV were collected. Descriptive statistical analysis were performed in Excel. Results The mean age was 54 years. The average time after HT to PCSK9 initiation ranged from one month to 28 years. Two patients were treated for refractory hyperlipidemia, while the remaining were statin intolerant. All patients tolerated evolocumab 140 mg subcutaneously every two weeks, with no reported side effects. The average time on PCSK9 inhibitor therapy was 14 months. Six patients have follow up LDL values at 3 months after starting therapy. In this group the LDL decreased from a mean of 146.2 mg/ dL prior to therapy to 78.1 mg/ dL after 1-3 months of treatment (p = 0.016). One patient was intolerant to both statin therapy and everolimus. In this patient we saw an improvement in CAV at 1 year angiographic follow up. Conclusion Use of PCSK9 inhibitors in this small single-center cohort appears to be safe and effective. While this therapy has known benefit for atherosclerosis, additional research is needed to understand whether there are anti-inflammatory properties that may stabilize or improve CAV in a larger cohort of HT recipients.

Purpose Continuous home inotropic therapy (HIT) is used as a bridge to heart transplant (BTT), ventricular assist device (BTVAD), decision regarding advanced therapies (BTD), for optimization of oral therapy and inotrope wean (OMT) and for palliative care (PC). While HIT may reduce symptoms, improve functional status and allow time for advanced care decisions, contemporary data on whether the goal of therapy was achieved are limited. Methods This is a single center, retrospective study of hospitalized patients initiated on HIT from 1/1/2013 - 7/1/2017. Outcomes included whether the intended goal of HIT was achieved, need for re-hospitalization within 1 year of HIT initiation and mortality. Results 241 patients (mean age 60.7±10.2 years; 71% male) were discharged on HIT (90% milrinone). Etiology was ischemic in 36.1%. Mean EF was 19.4±10.2%, PCWP 24.0±8.6 mmHg and Fick CI 1.6±0.4 L/min/m2 prior to HIT initiation. At 1 year, 99% of BTT and BTVAD patients reached OHT, VAD or were alive on HIT (Table 1). For BTT, 23.5% reached OHT but 28.4% required VAD. For BTVAD, 82.9% reached VAD within 1 year, with mean time to VAD of 79±79 days. For BTD, survival was 64% at 1 year, indicating that co-morbidities or other characteristics contributed to difficult decision-making and moving these patients to a definitive pathway. For OMT, 30% of patients were weaned off inotropes and 3 died within 1 year. For PC, only 25% had palliative care consults prior to discharge. Interestingly, 8 patients were alive for > 3 years on HIT (1BTT, 4 OMT, and 3 PC). Conclusion HIT is a reasonable therapy for some patients with advanced heart failure, although unplanned re-hospitalization remains high. HIT represents a step toward a VAD decision and in some cases a viable BTT pathway. HIT for PC is a growing strategy as more time with greater quality might be afforded. For OMT or BTD, there is more uncertainty regarding the safety and efficacy of HIT. Further work in a multicenter registry is needed to better understand the role of HIT.